Nursing Care Plan Wellness Diagnosis: A Comprehensive Guide for Nurses

Nursing diagnoses are the cornerstone of effective patient care. As a vital step in the nursing process, they enable nurses to identify patient needs, plan appropriate interventions, and evaluate outcomes. This guide provides an in-depth exploration of nursing diagnoses, with a particular focus on wellness diagnoses and their crucial role in developing holistic nursing care plans.

Understanding Nursing Diagnosis

A nursing diagnosis is defined as a clinical judgment about individual, family, group, or community responses to actual or potential health problems and life processes. It forms the foundation for selecting nursing interventions to achieve patient-centered outcomes, holding nurses accountable for the care they provide. Nursing diagnoses are derived from comprehensive data gathered during the nursing assessment, guiding the development of personalized care plans.

The Significance of Nursing Diagnosis

Nursing diagnoses serve several critical purposes within healthcare:

Enhancing Problem-Solving and Critical Thinking: For nursing students, formulating nursing diagnoses is an invaluable exercise in sharpening problem-solving and critical thinking abilities.
Prioritizing Nursing Care: Nursing diagnoses help establish priorities, directing nursing interventions towards the most pressing patient needs.
Formulating Expected Outcomes: They are essential for defining measurable outcomes, which are crucial for quality assurance and reimbursement from healthcare payers.
Understanding Patient Responses: Nursing diagnoses illuminate how patients respond to health challenges and life events, identifying available strengths and resources to address problems effectively.
Facilitating Communication: They establish a common language among nursing professionals and the broader healthcare team, promoting clear and efficient communication.
Evaluating Nursing Care Effectiveness: Nursing diagnoses provide a framework for evaluating the benefits and cost-effectiveness of nursing interventions, ensuring optimal patient outcomes.

Nursing Diagnosis vs. Medical Diagnosis vs. Collaborative Problems

It’s crucial to distinguish between nursing diagnoses, medical diagnoses, and collaborative problems.

Nursing diagnoses are centered on the patient’s response to a medical condition. They address the patient’s physical, psychological, and spiritual needs within the scope of nursing practice. For example, a patient with pneumonia may have the nursing diagnosis “Ineffective Airway Clearance related to increased mucus production.”

Medical diagnoses, on the other hand, are made by physicians or advanced practitioners and focus on the disease or pathology itself. They identify the specific illness that medical professionals treat. Examples include Pneumonia, Diabetes Mellitus, or Heart Failure. Medical diagnoses dictate medical treatments, while nursing diagnoses guide nursing care.

Collaborative problems are potential complications arising from medical conditions that require both medical and nursing interventions. Nurses monitor for these potential problems and implement interventions in collaboration with physicians. For instance, a patient post-surgery is at risk for infection – a collaborative problem requiring both medical (antibiotics) and nursing (wound care, monitoring) interventions.

The key difference lies in focus: nursing diagnoses address patient responses and care, while medical diagnoses address diseases and medical treatment.

Taxonomy of Nursing Diagnoses (NANDA-I)

Nursing diagnoses are systematically classified by the NANDA-I (North American Nursing Diagnosis Association International) taxonomy. This hierarchical system organizes diagnoses into:

Domains (13): Broad areas of health and functioning (e.g., Health Promotion, Nutrition, Activity/Rest).
Classes (47): Subcategories within domains (e.g., Health Management, Ingestion, Sleep/Rest).
Nursing Diagnoses: Specific diagnostic labels within classes, alphabetically listed by concept.

This taxonomy, revised periodically, provides a standardized language for nursing diagnoses, facilitating communication and research.

The 13 NANDA-I Domains are:

Health Promotion: Focuses on awareness and activities to maintain or improve wellness.
Nutrition: Addresses activities related to intake and utilization of nutrients.
Elimination and Exchange: Concerned with secretion and excretion of waste products.
Activity/Rest: Covers activities of daily living, exercise, sleep, and energy balance.
Perception/Cognition: Relates to sensory and cognitive processes.
Self-Perception: Focuses on self-concept, self-esteem, and body image.
Role Relationship: Addresses roles and relationships within social contexts.
Sexuality: Concerned with sexual identity, function, and reproduction.
Coping/Stress Tolerance: Relates to adaptation and stress management.
Life Principles: Focuses on values, beliefs, and spiritual well-being.
Safety/Protection: Addresses safety and protection from harm, including infection and injury.
Comfort: Relates to physical, environmental, and social comfort.
Growth/Development: Covers age-appropriate growth and development.

The Nursing Process and Nursing Diagnosis

Nursing diagnosis is the second step of the nursing process, a systematic approach to patient care encompassing five stages:

Assessment: Gathering subjective and objective data about the patient’s health status.
Diagnosis: Analyzing assessment data to identify nursing diagnoses.
Planning: Developing a care plan with patient-centered goals and nursing interventions.
Implementation: Carrying out the planned nursing interventions.
Evaluation: Assessing the effectiveness of interventions and patient progress towards goals.

Each stage of the nursing process relies on critical thinking. Nurses must understand nursing diagnoses, their defining characteristics, related factors, and appropriate interventions to provide effective and individualized care.

For a more detailed exploration of the nursing process, refer to: “The Nursing Process: A Comprehensive Guide“

Types of Nursing Diagnoses: Including Wellness Diagnosis

There are four primary types of nursing diagnoses: Problem-Focused (Actual), Risk, Health Promotion (Wellness), and Syndrome.

1. Problem-Focused (Actual) Nursing Diagnosis

A problem-focused nursing diagnosis, also known as an actual diagnosis, identifies a current patient problem present at the time of assessment. It’s supported by defining signs and symptoms. While crucial, actual diagnoses aren’t always the highest priority; risk diagnoses can be equally or more important in preventing potential complications.

Problem-focused diagnoses have three components:

Nursing Diagnosis Label: The NANDA-I approved diagnostic term (e.g., Acute Pain).
Related Factors: The “related to” phrase identifies the cause or contributing factors (e.g., related to surgical incision).
Defining Characteristics: The “as evidenced by” phrase lists the signs and symptoms observed (e.g., as evidenced by patient reporting pain level of 7/10 and guarding behavior).

Example: Acute Pain related to surgical incision as evidenced by patient reporting pain level of 7/10 and guarding behavior.

2. Risk Nursing Diagnosis

A risk nursing diagnosis identifies potential problems a patient is vulnerable to developing. It indicates that risk factors are present, making the problem likely to occur without nursing intervention. Risk diagnoses are proactive, focusing on prevention and early intervention.

Risk diagnoses are based on:

Current health status
Past health history
Identified risk factors

Risk diagnoses include two components:

Risk Diagnostic Label: The NANDA-I approved label preceded by “Risk for” (e.g., Risk for Infection).
Risk Factors: The “as evidenced by” phrase lists factors increasing vulnerability (e.g., as evidenced by surgical wound, compromised immune system).

Example: Risk for Infection as evidenced by surgical wound and compromised immune system.

3. Health Promotion (Wellness) Diagnosis

A health promotion diagnosis, also known as a wellness diagnosis, focuses on a patient’s desire and motivation to enhance well-being and health. It identifies a patient’s readiness to improve their current health status. Wellness diagnoses are positive and strengths-based, emphasizing growth and potential.

Key characteristics of health promotion diagnoses:

Focus on enhancing wellness, not just addressing problems.
Reflect patient’s motivation and readiness for improvement.
Can apply to individuals, families, or communities.

Components of a health promotion diagnosis:

Diagnostic Label: Typically a one-part statement (e.g., Readiness for Enhanced Nutrition).
Related Factors (Optional): Can be added for clarity, often reflecting patient motivation (e.g., Readiness for Enhanced Nutrition related to expressed interest in healthy eating).

Examples of Health Promotion Diagnoses:

Readiness for Enhanced Knowledge (Disease Management)
Readiness for Enhanced Spiritual Well-being
Readiness for Enhanced Breastfeeding
Readiness for Enhanced Self-Care

Wellness Diagnosis and Nursing Care Plans:

Wellness diagnoses are particularly important for nursing care plans focused on health promotion and preventative care. They guide nurses in developing interventions to:

Support patient’s strengths and resources.
Educate and empower patients to make healthy choices.
Facilitate positive lifestyle changes.
Promote optimal functioning and quality of life.

For instance, a nursing care plan for “Readiness for Enhanced Nutrition” might include interventions such as:

Providing education on balanced dietary intake.
Collaborating with a dietitian for personalized meal planning.
Setting achievable goals for dietary changes with the patient.
Connecting the patient with community resources for healthy food access.

By incorporating wellness diagnoses into care plans, nurses can shift from a solely problem-focused approach to a more holistic model that emphasizes patient empowerment and proactive health management.

4. Syndrome Diagnosis

A syndrome diagnosis represents a cluster of actual or risk nursing diagnoses predicted to occur together due to a specific event or situation. Syndrome diagnoses are also one-part statements using only the diagnostic label.

Examples of Syndrome Diagnoses:

Rape-Trauma Syndrome
Relocation Stress Syndrome
Impaired Environmental Interpretation Syndrome

5. Possible Nursing Diagnosis

A possible nursing diagnosis indicates a suspected problem requiring further data to confirm or rule out. It is not a formal type of diagnosis but a tool for communication among nurses, signaling a need for further assessment.

Example: Possible Spiritual Distress related to uncertain prognosis. (Further assessment needed to confirm spiritual distress).

Components of a Nursing Diagnosis Statement

A complete nursing diagnosis statement typically includes three components, especially for problem-focused diagnoses:

Problem (Diagnostic Label): A concise statement of the patient’s health problem. It often includes a qualifier (modifier) to add specificity (e.g., Deficient Fluid Volume, Impaired Gas Exchange).
Etiology (Related Factors): Identifies the probable cause(s) or contributing factors, linked to the problem with “related to.”
Defining Characteristics (Signs and Symptoms): Observable cues indicating the presence of the problem, linked with “as evidenced by.” For risk diagnoses, risk factors replace defining characteristics and are linked with “as evidenced by.”

The Diagnostic Process

Diagnosing involves a three-phase process:

Data Analysis: Comparing patient data to norms, clustering cues, and identifying inconsistencies.
Problem/Risk/Strength Identification: Identifying health problems, risks, and strengths based on data analysis. Differentiating between nursing, medical, and collaborative problems.
Diagnostic Statement Formulation: Creating clear and concise nursing diagnosis statements.

Writing Effective Nursing Diagnosis Statements

When writing nursing diagnoses:

Be precise and use NANDA-I approved terminology.
Focus on patient responses, not nurse needs.
Use “related to” to link problem and etiology.
Use “as evidenced by” to link problem and defining characteristics/risk factors.
Avoid medical diagnoses within nursing diagnosis statements.
Ensure the diagnosis is ethically and legally sound.

PES Format:

A helpful mnemonic for writing problem-focused diagnoses is PES:

Problem (Diagnostic Label)
Etiology (Related Factors)
Signs/Symptoms (Defining Characteristics)

Variations in Statement Format:

One-part statements: Used for health promotion and syndrome diagnoses (diagnostic label only).
Two-part statements: Used for risk and possible diagnoses (diagnostic label + risk factors/validation).
Three-part statements: Used for problem-focused diagnoses (PES format).

Nursing Diagnoses for Care Plans: A Foundation for Patient-Centered Care

Nursing diagnoses are integral to developing effective nursing care plans. They provide a structured framework for:

Identifying patient needs and problems.
Setting realistic and measurable patient goals.
Selecting appropriate nursing interventions.
Evaluating the effectiveness of care.

By accurately identifying and utilizing nursing diagnoses, especially wellness diagnoses, nurses can create comprehensive, patient-centered care plans that promote healing, health, and well-being.

See also: Nursing Care Plans (NCP): Ultimate Guide and List

Recommended Resources for Nursing Diagnosis and Care Planning

To further enhance your understanding and skills in nursing diagnosis and care planning, consider these valuable resources:

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
This handbook offers an evidence-based approach to nursing interventions, guiding you through assessment, diagnosis, and care planning with a user-friendly three-step system.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
This comprehensive resource includes over 200 care plans reflecting the latest evidence-based guidelines, including ICNP diagnoses and considerations for LGBTQ health.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
A quick-reference tool for accurate diagnosis and efficient care planning, featuring the most recent nursing diagnoses and interventions for over 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
This manual provides detailed interventions for planning, individualizing, and documenting care for over 800 diseases and disorders, offering sample clinical applications and prioritized actions.

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
This e-book offers over 100 care plans across various specialties, familiarizing you with interprofessional patient problems and communication.

References and Sources

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Gordon, M. (1982). Nursing diagnosis: Process and application. New York: McGraw-Hill.
Gordon, M. (2014). Manual of nursing diagnosis. Jones & Bartlett Publishers.
Gebbie, K., & Lavin, M. (1975.) Classification of nursing diagnoses: Proceedings of the First National Conference. St. Louis, MO: Mosby.
McManus, R. L. (1951). Assumption of functions in nursing. In Teachers College, Columbia University, Regional planning for nurses and nursing education. New York: Columbia University Press.
Powers, P. (2002). A discourse analysis of nursing diagnosis. Qualitative health research, 12(7), 945-965.